Results Summary
What was the research about?
The rate of major depressive disorder, or MDD, among teens has gone up over the last decade. Having MDD increases the risk for suicide, the second leading cause of death among teens. School-based screening can help identify teens with MDD and get them treatment.
In Pennsylvania, all schools have the Student Assistance Program, or SAP, that helps students with issues affecting success in school. Trained SAP staff can confirm if MDD symptoms require follow-up and refer students to school or community services if needed.
In this study, the research team compared two types of MDD screening for high school students:
- Universal, or broad screening. All students completed a nine-question screener for MDD on an iPad. Students with MDD symptoms received a referral to their school’s SAP. Any student with suicidal thoughts received immediate services.
- Targeted, or focused screening. Teachers, staff, and parents referred any students with concerning behavior to their school’s SAP. Schools in Pennsylvania currently use this approach for screening.
The research team wanted to learn which type of screening identified more students with MDD and helped get them treatment, especially those often missed in focused screening.
What were the results?
By the end of the school year, compared with students who received focused screening, students who received broad screening were:
- Almost six times more likely to have their MDD symptoms identified through their school
- More than three times more likely to have their need for follow-up services confirmed by the SAP
- Two times more likely to start MDD treatment
Compared with focused screening, broad screening was better at identifying MDD among students who were female, Hispanic, or a race other than White or Black. These students are often missed in focused screening.
Rates of starting treatment didn’t differ by student sex, race, or ethnicity between the two types of screening.
Who was in the study?
The study included 12,909 students in 14 public high schools in Pennsylvania. Among students, 45 percent were White, 22 percent were Black, 21 percent were Hispanic, and 12 percent were another race or ethnicity. The median age was 16, and 54 percent were boys.
What did the research team do?
The research team assigned schools by chance to offer broad screening to students in either 9th and 11th grades, or 10th and 12th grades. Students in the other grades received focused screening.
School SAP teams tracked students who came to see them, who they referred for services, and who started treatment.
School staff, physical and mental health clinicians and advocates, parents, and teens provided input throughout the study.
What were the limits of the study?
Schools that chose to take part in the study had strong SAP teams. Results may differ for schools that don’t have SAP teams or whose teams are less prepared.
Future studies could look at broad screening for MDD in high schools in other states.
How can people use the results?
Schools can use these results when looking at how to identify students with MDD and get them treatment.
Professional Abstract
Objective
To compare the effectiveness of universal versus targeted, school-based screening for major depressive disorder (MDD) in increasing treatment initiation among high school students
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 12,909 students attending 14 public high schools in Pennsylvania |
| Interventions/ Comparators |
|
| Outcomes |
Primary: initiation of recommended treatment for MDD through school-based identification of symptoms Secondary: school identification of MDD symptoms, SAP confirmation of the need for follow-up services |
| Timeframe | Follow-up by end of school year for primary outcome |
This randomized controlled trial compared two school-based approaches for screening students for MDD.
In Pennsylvania, all schools have the Student Assistance Program (SAP) staffed with professionals trained to address issues affecting student academic success. For each student screened and referred to the SAP for MDD, the SAP team confirms symptoms, determines whether additional assessment or treatment is necessary, and, if so, provides a referral.
The two screening approaches were:
- Universal screening. All students completed a nine-question screener for MDD on an iPad. Those who screened positive received a referral to their school’s SAP. Any student indicating suicidal thoughts on the screener received immediate intervention, following the school’s crisis response protocol.
- Targeted screening. Teachers, staff, and parents referred any student exhibiting symptoms of MDD to the SAP. Pennsylvania schools currently use this screening approach.
Researchers wanted to understand whether universal screening identified more students with MDD and helped get them treatment, especially those often missed in targeted screening.
The research team randomized participating schools to conduct universal screening for students in either 9th and 11th grades, or 10th and 12th grades. The other grades received targeted screening as usual. Using state SAP reports, schools tracked and reported information about confirmation of MDD, referral for services, and treatment initiation.
The study included 12,909 students from 14 public high schools in Pennsylvania. Among students, 45% were White, 22% were Black, 21% were Hispanic, and 12% were another race or ethnicity. The median age was 16, and 54% were male.
School staff, physicians, mental health clinicians and advocates, parents, and adolescents provided input throughout the study.
Results
Compared with students who received targeted screening, students who received universal screening were:
- 5.92 times more likely to have their MDD symptoms identified (95% confidence interval [CI]: 5.07, 6.93)
- 3.30 times more likely to have the SAP confirm their need for follow-up services (95% CI: 2.49, 4.38)
- 2.07 times more likely to initiate MDD treatment (95% CI: 1.39, 3.10)
Compared with targeted screening, universal screening showed greater increases in identifying and confirming MDD among students who were female (identification: p<0.001; confirmation: p=0.005) and those who were Hispanic or a race other than White or Black (identification: p<0.001; confirmation: p=0.007).
Rates of treatment initiation did not differ significantly by sex, race, or ethnicity between the two screening approaches.
Limitations
Only schools with SAP teams well equipped to manage increased referrals chose to participate in the study. Results may differ for schools that do not have SAP teams or whose SAP teams are less prepared.
Conclusions and Relevance
In this study, high school students who received universal screening were more likely to initiate MDD treatment than students who received targeted screening. Also, universal screening helped identify MDD among students often missed by targeted screening.
Future Research Needs
Future research could examine universal MDD screening in high schools outside of Pennsylvania.
Final Research Report
This project's final research report is expected to be available by September 2023.
Engagement Resources
Journal Citations
Results of This Project
Related Journal Citations
Stories and Videos
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked for clarification about the measurement of primary outcome for the study and whether the outcome was a composite as described in their Clinicaltrials.gov registration. The researchers explained the three parts of the primary outcome: identification of depression symptoms, confirmation that the symptoms warrant further evaluation, and initiation of treatment by the student identified. The researchers examined the percentage of each of these outcomes out of the total students in each trial arm. The researchers explained that they had initially considered this a composite outcome but previous reviewers preferred for the three metrics to be discussed individually.
- The reviewers expressed concern about the delivery of the intervention by school staff rather than trained professionals and the resulting low rate of treatment initiation for students exhibiting depressive symptoms. The researchers explained that staff confirming depression diagnoses were trained for this work, and that requiring an outside professional to confirm diagnoses would have made implementation of the universal screening more prohibitive for many schools. The researchers also acknowledged the low rate of treatment initiation compared to the number of students identified as depressed but noted that they only measured treatment initiation within the Student Assistance Program and did not track whether students received treatment outside of the program.